This blog was created for Niles Animal Hospital & Bird Medical Center by Peter S. Sakas DVM in an effort to provide information & discussion about animal related issues. It may move into some eccentric directions on occasion if the mood strikes me as I get more comfortable in this form of communication. I am open to suggestions & comments about the blog. Also view our hospital website www.nilesanimalhospital.com or Facebook page Niles Animal Hospital and Bird Medical Center.

Questions, Answers, and Interim Guidelines

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Q:What is canine influenza?A: Canine influenza (CI), or dog flu, is a highly contagious respiratory infection of dogs that is caused by an influenza A virus. In the U.S., canine influenza has been caused by two influenza strains. The first strain reported in the United States, beginning in 2004, was an H3N8 influenza A virus. This strain is closely related to the virus that causes equine influenza, and it is thought that the equine influenza virus mutated to produce the canine strain. In 2015, an outbreak that started in Chicago was caused by a separate canine influenza virus, H3N2. The strain causing the 2015 outbreak was almost genetically identical to an H3N2 strain previously reported only in Asia – specifically, Korea, China and Thailand. In Asia. This H3N2 strain is believed to have resulted from the direct transfer of an avian influenza virus – possibly from among viruses circulating in live bird markets – to dogs. Since March 2015, thousands of dogs have been confirmed positive for H3N2 canine influenza across the U.S.

Two clinical syndromes have been seen in dogs infected with the canine influenza virus—a mild form of the disease and a more severe form that is accompanied by pneumonia.

Mild form — Dogs suffering with the mild form of canine influenza develop a soft, moist cough that persists for 10 to 30 days. They may also be lethargic and have reduced appetite and a fever. Sneezing and discharge from the eyes and/or nose may also be observed. Some dogs have a dry cough similar to the traditional "kennel cough" caused by Bordetella bronchiseptica/parainfluenza virus complex. Dogs with the mild form of influenza may also have a thick nasal discharge, which is usually caused by a secondary bacterial infection.

Severe form — Dogs with the severe form of canine influenza develop high fevers (104ºF to 106ºF) and have clinical signs of pneumonia, such as increased respiratory rates and effort. Pneumonia may be due to a secondary bacterial infection.

Q:Are all dogs at risk of getting canine influenza?A: Because this is still an emerging disease and dogs in the U.S. have not been exposed to it before, almost all dogs, regardless of breed or age, lack immunity to it and are susceptible to infection if exposed to the active virus. Virtually all dogs exposed to the virus become infected, and nearly 80% show clinical signs of disease, though most exhibit the mild form described above.

However, the risk of any dog being exposed to the canine influenza virus depends on that dog’s lifestyle. Dogs that are frequently or regularly exposed to other dogs – for example at boarding or day care facilities, dog parks, grooming salons, or social events with other dogs present – are at greater risk of coming into contact with the virus. Also, as with other infectious diseases, extra precautions may be needed with puppies, elderly or pregnant dogs, and dogs that are immunocompromised. Dog owners should talk with their own veterinarian to assess their dog’s risk.

Q:Do dogs die from canine influenza?A: Fatal cases of pneumonia resulting from infection with canine influenza virus have been reported in dogs, but the fatality rate is low (less than 10%). Most dogs recover in 2-3 weeks.

Q:How widespread is the disease?A: The first recognized outbreak of canine influenza in the world is believed to have occurred in racing greyhounds in January 2004 at a track in Florida. From June to August of 2004, outbreaks of respiratory disease were reported at 14 tracks in 6 states (Alabama, Arkansas, Florida, Kansas, Texas, and West Virginia). Between January and May of 2005, outbreaks occurred at 20 tracks in 11 states (Arizona, Arkansas, Colorado, Florida, Iowa, Kansas, Massachusetts, Rhode Island, Texas, West Virginia, and Wisconsin). The canine influenza virus has been reported in at least 40 states and Washington, DC.

The H3N2 strain of canine influenza virus had been reported in Korea, China and Thailand, but had not been detected outside of those countries until 2015. In April 2015, an outbreak that started in Chicago was determined to be caused by an H3N2 strain that was genetically almost identical to the one one in Asia. Since May 2015, thousands of dogs have been confirmed positive for H3N2 canine influenza across the U.S.

Q: Is there a vaccine?A: The first canine vaccine for H3N8 canine influenza was approved in 2009, and there are several H3N8 canine influenza vaccines available. It is not known whether the H3N8 vaccine will offer any protection against the H3N2 strain. Canine influenza vaccines are considered "lifestyle" vaccines, meaning the decision to vaccinate is based on a dog’s risk of exposure. Dog owners should consult their veterinarian to determine whether vaccination is needed.

Q:How is a dog with canine influenza treated?A: As with any disease caused by a virus, treatment is largely supportive. Good animal care practices and nutrition assist dogs in mounting an effective immune response.

The course of treatment depends on the pet's condition, including the presence or absence of a secondary bacterial infection, pneumonia, dehydration, or other medical issues (e.g., pregnancy, pre-existing respiratory disease, compromised immune system, etc.). The veterinarian might prescribe medications, such as an antibiotic (to fight secondary infections) and/or a nonsteroidal anti-inflammatory (to reduce fever, swelling and pain). Dehydrated pets may need fluid therapy to restore and maintain hydration. Other medications, or even hospitalization, may also be necessary for more severe cases.

Q:Is canine influenza virus transmissible from dogs to humans?A: To date, there is no evidence of transmission of canine influenza virus from dogs to people.

Q:Is canine influenza virus transmissible from dogs to cats, horses or other animal species?A: At this time, there is no evidence of transmission of H3N8 canine influenza from dogs to horses, cats, ferrets, or other animal species. The H3N2 strain, however, has been reported in Asia to infect cats, and there’s also some evidence that guinea pigs and ferrets can become infected.

Precautions to prevent spread of the virus are outlined below, in the answer to "I work in a kennel/animal care facility. What should I do to prevent transmission of influenza virus from infected dogs to susceptible dogs?"

Q:Do I need to be concerned about putting my dog in day care or boarding it at a kennel?A: Dog owners should be aware that any situation that brings dogs together increases the risk of spread of communicable illnesses. Good infection control practices can reduce that risk, so dog owners involved in shows, sports, or other activities with their dogs or who board their dogs at kennels should ask whether respiratory disease has been a problem there, and whether the facility has a plan for isolating dogs that develop respiratory disease and for notifying owners if their dogs have been exposed to dogs with respiratory disease.

As long as good infection control practices are in place, pet owners should not be overly concerned about putting dogs in training facilities, dog parks, kennels, or other areas frequented by dogs.

Q:My dog has a cough...what should I do?A: Consult your veterinarian. Coughing can be caused by many different medical problems, and your veterinarian can examine and evaluate your dog and recommend an appropriate course of treatment. If canine influenza is suspected, treatment will usually focus on maximizing the ability of your dog's immune system to combat the virus. A typical approach might include administration of fluids if your dog is becoming dehydrated and prescribing an antimicrobial if a secondary bacterial infection is suspected.

Canine influenza virus can be spread via direct contact with respiratory secretions from infected dogs (via barking, coughing or sneezing), and by contact with contaminated inanimate objects. Therefore, dog owners whose dogs are coughing or exhibiting other signs of respiratory disease should not participate in activities or bring their dogs to facilities where other dogs can be exposed to them. Clothing (including shoes), equipment, surfaces, and hands should be cleaned and disinfected after exposure to dogs showing signs of respiratory disease to prevent transmission of infection to susceptible dogs. Clothing can be adequately cleaned by using a detergent at normal laundry temperatures.

Q:I manage a kennel/veterinary clinic/animal shelter/dog day care center. How do I keep canine influenza out of my facility, and if it does enter my facility, what should I do?A: Viral disease is usually best prevented through vaccination. A vaccine against H3N8 canine influenza has been available since 2009, and H3N2 vaccines were conditionally approved in late 2015. It is considered a "lifestyle" vaccine, which means that the decision to vaccinate a dog against CIV is based on the risk of exposure. A veterinarian should determine whether vaccination is needed based on related risks and benefits, and should administer these vaccinations at least 2 weeks prior to planned visits to dog activity and care facilities (e.g., kennels, veterinary clinics, dog day care centers, training facilities, dog parks). This differs from "core" vaccines - such as distemper, parvo and rabies - that are required for all dogs, regardless of lifestyle.

Vaccination against other pathogens causing respiratory disease (such as Bordetella, adenovirus and parainfluenza) may help prevent more common respiratory pathogens from becoming secondary infections in a respiratory tract already compromised by influenza infection.

Routine infection control precautions are key to preventing spread of viral disease within facilities. The canine influenza virus appears to be easily killed by disinfectants (e.g., quaternary ammonium compounds, potassium peroxymonosulfate and bleach solutions at a 1 to 30 dilution) in common use in veterinary clinics, boarding facilities, and animal shelters. Protocols should be established for thoroughly cleaning and disinfecting cages, bowls, and other surfaces between uses. Employees should wash their hands with soap and water (or use an alcohol-based hand cleaner if soap and water are unavailable) before and after handling each dog; after coming into contact with a dog's saliva, urine, feces, or blood; after cleaning cages; and upon arriving at and before leaving the facility. (See "I work in a kennel/animal care facility. What should I do to prevent transmission of influenza virus from infected dogs to susceptible dogs?")

Animal care facility staff should be alerted to the possibility that a dog with a respiratory infection could be presented for care or boarding. If a dog with respiratory signs is presented, staff members should inquire whether the dog has recently been boarded or adopted from a shelter, has recently participated in dog-related group activities, or has been exposed to other dogs known to have canine influenza or kennel cough. The dog should be brought directly into a separate examination/triage area that is reserved for dogs with respiratory signs and should not be allowed to enter the waiting room or other areas where susceptible dogs may be present.

Dogs with suspected canine influenza virus infection discovered after entry into the facility should be evaluated and treated by a veterinarian. Isolation protocols should be rigorously applied for dogs showing signs of respiratory disease, including the wearing of disposable gloves by persons handling infected dogs or cleaning contaminated cages. Respiratory disease beyond what is considered typical for a particular facility should be investigated, and the investigation should include submission of appropriate diagnostic samples. (See "What diagnostic tests will tell me whether a dog has canine influenza?")

Q:What diagnostic tests will tell me whether a dog has canine influenza? What samples do I send? Where do I send the samples? How do I distinguish between canine influenza and kennel cough?A: There is no rapid test for the specific diagnosis of acute canine influenza virus infection. Nasal or throat swabs from dogs that have been ill for less than 3 days may be sent to a diagnostic laboratory for testing. Your veterinarian may also offer other testing, such as an in-house test to detect influenza types A and B.

Antibodies to canine influenza virus may be detected as early as seven days after onset of clinical signs. Convalescent-phase samples should be collected at least two weeks after collection of the acute-phase sample. If an acute-phase sample is not available, testing a convalescent-phase sample can reveal whether a dog has been infected with or exposed to CIV at some point in the past.

For dogs that have died from pneumonia or other conditions in which CIV is suspected, additional diagnostic tests are available to your veterinarian through reference laboratories.

Q:I work in a kennel/animal care facility. What should I do to prevent transmission of influenza virus from infected dogs to susceptible dogs?A: Canine influenza is not known to be transmissible from dogs to people. However, caretakers can inadvertently transmit canine influenza virus from infected dogs to susceptible dogs by not following good hygiene and infection control practices. To prevent spread of canine influenza virus, caretakers should take the following precautions:

Wash hands with soap and water (if soap and water are unavailable, use an alcohol-based hand cleaner):

Upon arriving at the facility

Before and after handling each animal

After coming into contact with animal saliva, urine, feces or blood

After cleaning cages

Before eating meals, taking breaks, smoking or leaving the facility

Before and after using the restroom

Wear a barrier gown over your clothes and wear gloves when handling sick animals or cleaning cages. Discard gown and gloves before working with other animals.

Consider use of goggles or face protection if splashes from contaminated surfaces may occur.

Bring a change of clothes to wear home at the end of the day.

Thoroughly clean clothes worn at the animal facility.

Do not allow animals to "kiss" you or lick your face.

Do not eat in the animal care area.

Separate newly arriving animals from animals that have been housed one week or longer.

There is no evidence of transmission of canine influenza virus from dogs to people. However, because of concerns about diseases that are transmissible from dogs to people, in general, it may be prudent for young children, the elderly, pregnant women, and immunocompromised persons to limit or avoid contact with animals that are ill.

Wednesday, January 13, 2016

Below the surface of anesthesia-free dentistry

​Service is growing, but veterinary organizations say cleanings should be done under anesthesia

By Katie Burns

Posted Jan. 13, 2016

The American Veterinary Dental College is waging a campaign against anesthesia-free dentistry for dogs and cats, complete with a new website for pet owners and general practitioners.

At the same time, Pet Dental Services Inc., a national provider of anesthesia-free dentistry, is moving forward on a study with the working title “A comparison of oral examinations and dental cleanings in non-anesthetized and anesthetized dogs.”

The AVMA and American Animal Hospital Association recently stated that dental cleanings should be performed under anesthesia. According to the 2013 AAHA Dental Care Guidelines for Dogs and Cats, “General anesthesia with intubation is necessary to properly assess and treat the companion animal dental patient.”

Anesthesia-free dentistry is growing across the country, nevertheless, as many pet owners perceive a need for pet dental care but fear the risks of anesthesia—and as more general practitioners offer the service, generally via a third-party provider.

AVDC position

The 2004 AVDC position statement “Companion Animal Dental Scaling Without Anesthesia” states that the procedure is inappropriate for a number of reasons.

“Even slight head movement by the patient could result in injury to the oral tissues of the patient, and the operator may be bitten when the patient reacts,” according to the statement. Also, “access to the subgingival area of every tooth is impossible in an unanesthetized canine or feline patient.”

According to the statement, inhalation anesthesia with intubation provides three advantages: “... the cooperation of the patient with a procedure it does not understand, elimination of pain resulting from examination and treatment of affected dental tissues during the procedure, and protection of the airway and lungs from accidental aspiration.”

Also according to the statement, “A complete oral examination, which is an important part of a professional dental scaling procedure, is not possible in an unanesthetized patient.”

The AVDC launched its website on anesthesia-free dentistry, www.avdc.org/AFD, about a year ago. The college collaborated on the site with the Academy of Veterinary Dentistry. The sections of the site are “The Facts,” “For Pet Owners,” and “For Veterinarians.”

Dr. Curt Coffman of Arizona Veterinary Dental Specialists, an AVDC board member, said providers of anesthesia-free cleanings are able to clean some parts of the mouth but cannot see or reach all the parts. The teeth look cleaner, he said, “but yet, there are other parts of the mouth that haven’t even been examined, let alone cleaned, and those parts can still be diseased.”

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​Dr. Curt Coffman of Arizona Veterinary Dental Specialists found multiple areas of periodontal disease below the gumline in a 5-year-old Cavalier King Charles Spaniel during an oral examination and dental radiography, both performed under anesthesia. In all, Dr. Coffman extracted 15 teeth. The dog had received anesthesia-free dental cleanings by a veterinarian. (Courtesy of Dr. Curt Coffman)

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Effective in 2014, Dr. Coffman’s neighboring Nevada amended the state veterinary practice act to require that veterinary dentistry—including cleanings—be performed under anesthesia.

Dr. Coffman said clients need education about anesthesia. He said, “No matter what your dog and cat’s age or what your dog or cat’s condition, almost every pet can have anesthesia.”

The AVDC position statement does not address radiography, but Dr. Coffman noted that intraoral radiography allows for evaluation of the whole mouth above and below the gumline beyond what a veterinarian can see even in anesthetized patients. He noted that dogs and cats really do need to be asleep for radiography.

Pet Dental Services

Joshua Bazavilvazo, Pet Dental Services founder and chief executive officer, said a pilot study of his company’s 11-step procedure for anesthesia-free cleanings sparked the interest of many in the veterinary community.

The pilot study involved 12 dogs, and the follow-up study now in progress involves 60. The investigators on the current study include two veterinary dentists and two veterinary technician dental specialists. The hope is to complete the study by the summer.

“I know what we do is beneficial for the pet, and it is a viable medical procedure that can be proven,” Bazavilvazo said.

Many pet owners want anesthesia-free dentistry, Bazavilvazo said. He said they are considering factors such as preventive care, safety, expense, and convenience.

Pet Dental Services provides cleanings only under the supervision of veterinarians. Bazavilvazo considers anesthesia-free cleanings to be complementary to cleanings performed under anesthesia. He said, “At every single practice that we work in, the anesthetic dentals go up because we find so much pathology just during our oral examination, before the dental is even started.”

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​Pet Dental Services, a national provider of anesthesia-free dental cleanings, offers an 11-step procedure for cats and dogs, with all services provided under the supervision of a veterinarian. Joshua Bazavilvazo, the company’s founder and chief executive officer, considers the service to be complementary to cleanings performed under anesthesia. (Courtesy of Pet Dental Services)

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Anesthesia-free cleaning might be an option for a young dog with mild buildup. “Veterinarians say, ‘Well, you’re not quite ready for an anesthetic dental yet,’” Bazavilvazo said. “So we would fit in and be able to take care of the pet’s teeth as a preventive measure.”

In another scenario, a dog might undergo dental procedures under anesthesia to address pathologic changes, then an anesthesia-free cleaning six months later to remove buildup. Bazavilvazo said anesthesia-free cleanings also might be an option for pets that truly cannot go under anesthesia.

Pet Dental Services employees learn behavioral management techniques to enable them to clean pets’ teeth without anesthesia, Bazavilvazo said. After ruling out animals on which anesthesia-free dentistry cannot be performed because of behavior or pathologic lesions, employees are able to work with almost all dogs and about three-quarters of cats, he said.

Bazavilvazo believes veterinarians’ main concern with anesthesia-free cleanings is that there is no certification process for individuals performing these procedures. Plus, some providers of the service don’t work under the supervision of veterinarians, even though state practice acts generally define dental cleanings for cats and dogs as part of the practice of veterinary medicine.

AAHA and AVMA

Soon after the 2013 release of its dental guidelines, AAHA started requiring AAHA-accredited hospitals to anesthetize and intubate patients undergoing dental procedures, including dental cleanings.

“Cleaning a companion animal’s teeth without general anesthesia is considered unacceptable and below the standard of care,” according to the guidelines.

AVMA policy on anesthesia in veterinary dentistry

The following are the sections of the AVMA policy “Veterinary Dentistry” that cover anesthesia:

When procedures such as periodontal probing, intraoral radiography, dental scaling, and dental extraction are justified by the oral examination, they should be performed under anesthesia.

Sedatives, tranquilizers, anesthetics, or analgesics are commonly used during veterinary dental procedures to provide restraint and reduce animal pain and suffering. Visual or radiographic recognition of oral or dental pathology and accurate assessment of periodontal health by probing of pockets require sedation or anesthesia. An endotracheal tube is to be placed to protect the lungs from the water droplets generated during ultrasonic dental scaling or when a high-speed dental unit is used. Preoperative sedation, intra-operative local or regional analgesia and post-operative analgesics are used as indicated to reduce the dose of anesthetic agent required and ensure a smooth, pain-free recovery period. Federal law restricts such veterinary prescription drugs for use by, or on the order of, a licensed veterinarian to ensure their safe and effective use.

Dr. Heather Loenser, AAHA veterinary adviser for public and professional affairs, said anesthesia during dental procedures first allows for intubation to protect the airway. She said anesthesia also allows for thorough cleaning and for thorough evaluation of the oral cavity, including dental radiography.

“I think these points are very valid, and they resonate with veterinarians,” Dr. Loenser said.

Dr. Loenser believes that the biggest advance in veterinary dentistry recently has been an understanding of the importance of dental radiography. She said dental radiography has been a nonmandatory standard for AAHA-accredited hospitals since 2003.

In 2014, the AVMA House of Delegates approved adding the following statement to the AVMA policy on “Veterinary Dentistry”: “When procedures such as periodontal probing, intraoral radiography, dental scaling, and dental extraction are justified by the oral examination, they should be performed under anesthesia.”

The AVMA Council on Veterinary Service oversees the policy and has formed a subcommittee to investigate nonanesthetic dentistry. Dr. Christopher Gargamelli, a member of the subcommittee, believes the AVMA is unlikely to revise the policy before the regular five-year review unless scientific literature on the topic emerges.

After observing anesthesia-free dentistry, Dr. Gargamelli said that he personally can see a place for the service in veterinary practice but only under the supervision of a veterinarian and within a veterinarian-client-patient relationship as an addition to cleanings and radiography performed under anesthesia.

“Say you have a dental cleaning under anesthesia every one to two years. Some patients may need more dental care than that,” he said. “Having this nonanesthetic dentistry performed may be a good fit for that patient.”

In practice

Dr. John de Jong, chair of the AVMA Board of Directors and owner of Newton Animal Hospital in Newton, Massachusetts, offers anesthesia-free cleanings in his practice under contract with Animal Dental Care Inc., another national provider of the service.

Dr. de Jong was highly skeptical of the service until he saw a demonstration. All the dogs, including his two dogs, sat quietly as the company’s employees did a “very thorough and professional job,” he said.

He said, “For clients that refuse to have their pets undergo anesthesia or balk at the cost of a dentistry under anesthesia, I believe that a conscious dental cleaning can be a valuable adjunct to a complete and thorough oral health care plan.”

Dr. de Jong’s practice team tries to get clients to brush their animals’ teeth, but toothbrushing generally doesn’t happen. So when the veterinarians find tartar and plaque, they explain the options and costs to clients. If an animal obviously needs an extraction or further exploration, then an anesthesia-free cleaning is not an option.

Animal Dental Care refers to its procedure as preventive cleaning and assessment, Dr. de Jong noted, and the company still advocates for dental procedures and radiography under anesthesia.

Dr. de Jong considers anesthesia-free cleanings to be very successful at his hospital, and he has noticed the service growing across the country.

“I am hopeful that the AVMA and AAHA might consider changing their current positions on anesthesia-free dental cleanings,” Dr. de Jong said. “Like many other colleagues that I respect, I was willing to consider the possibility and clearly saw a place for these procedures.”